Provider Demographics
NPI:1316584436
Name:AVITA HOME CARE, INC
Entity Type:Organization
Organization Name:AVITA HOME CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATERYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RADETSKA GULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:773-840-5260
Mailing Address - Street 1:1043 S YORK RD STE 106A
Mailing Address - Street 2:
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106-3489
Mailing Address - Country:US
Mailing Address - Phone:773-840-5260
Mailing Address - Fax:773-840-5209
Practice Address - Street 1:1043 S YORK RD STE 106A
Practice Address - Street 2:
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-3489
Practice Address - Country:US
Practice Address - Phone:773-840-5260
Practice Address - Fax:773-840-5209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care